ANATOMY

Referred Abdominal Pain

- Feeling of pain at a location other than the side of origin of the stimulus but in an area
supplied by the same or adjacent segments of the spinal cord.
- Both somatic and visceral structures can produce referred pain.

Referred Somatic Pain

- Nerve fibers from diseased structure and the area where the pain is felt ascend in the central
nervous system along a common pathway
- Cerebral cortex is incapable of distinguishing between the sites.
Examples : Pleurisy involving the lower part of the costal parietal pleura can give rise to referred
pain in the abdomen.
Sensory innervation : Lower part of costal parietal pleura
By Lower 5 intercostal nerve which innervate the skin and muscles of the anterior abdominal
wall.

Referred Visceral Pain

1)Stomach
Referred pain : Epigastrium
- The afferent pain fibers from stomach ascend in company with sympathetic nerves and pass
through the celiac plexus and the greater splanchnic nerves.
- The sensory fibers enter the spinal cord at segments T5 to T9 and give rise to referred pain in
dermatomes T5 to T9 on the lower chest and abdominal walls.

2)Appendix (Due to distention of its lumen/spasm of its smooth muscle coat)

A) Referred pain : Region of umbilicus
- The afferent pain fibers from appendix ascend in company with sympathetic nerve through
the superior mesentric plexus and the lesser splanchnic nerve to spinal cord (T10 segment).
- The sensory fibers enter the spinal cord at segments T10 and give rise to referred pain in
dermatomes T10 on the region of umbilicus
B) Later, if the inflammatory process involves the parietal peritoneum, the severe somatic pain
dominates the clinical picture and is localised precisely in the right lower quadrant.
3)Gall bladder (patients with cholecystitis or gall stone colic)
A) Referred pain (Vague) : Dermatome (T5 to T9) The lower chest & Upper abdominal walls
- The afferent pain fibers from stomach ascend in company with sympathetic nerves and pass
through the celiac plexus and the greater splanchnic nerves.
- The sensory fibers enter the spinal cord at segments T5 to T9 and give rise to referred pain in
dermatomes T5 to T9 on the lower chest and abdominal walls.

B) If the inflammatory process spreads, involve the parietal peritoneum of the anterior
abdominal wall/peripheral diaphragm. The severe somatic pain is felt in the right upper
quadrant and through the back below the inferior angle of the scapula.
Involve Central diaphragmatic parietal peritoneum :
- Sensory innervation : Phrenic nerve (C3, C4 and C5)
- Referred pain over the shoulder because the skin in this area is innervated by the
supraclavicular nerves (C3 and C4)
EPIDEMIOLOGY
World

The global distributions of hepatitis A, B, and C infections are shown in Figure 35-11. There
are marked differences in the epidemiologic features of these infections. The risk of these
viruses being transmitted by transfusion today in the United States is markedly reduced as a
result of improved screening tests and the establishment of volunteer donor populations. It was
calculated in 1996 that the risk of transmission of HBV by blood transfusion was one in 63,000
and for HCV was one in 103,000.
Hepatitis A
1. HAV is widespread throughout the world.
2. Outbreaks of type A hepatitis are common in :
- Families and institutions
- Summer camps
- Day care centers
- Neonatal intensive care units
- Among military troops
- Crowded conditions and poor sanitation; most children in such circumstances become immune
by age 10 years.
3. The mode of transmission is by the fecal-oral route through close personal contact. Stool
specimens may be infectious for up to 2 weeks before to 2 weeks after onset of jaundice.
4. Recurrent epidemics are a prominent feature. Sudden, explosive epidemics of type A
hepatitis usually result from fecal contamination of a single source (e.g : drinking water, food, or
milk). The consumption of raw oysters or improperly steamed clams obtained from water
polluted with sewage has also resulted in several outbreaks of hepatitis.
5. The largest outbreak of this type occurred in Shanghai in 1988, when more than 300,000
cases of hepatitis A were attributed to uncooked clams from polluted water.
6. A multistate foodborne outbreak that was traced to frozen strawberries occurred in the
United States in 1997. Other identified sources of potential infection are non-human primates.
7. There have been more than 35 outbreaks in which primates, usually chimpanzees, have
infected humans in close personal contact with them.
8. In the United States in the pre-vaccine era, there were an estimated 271,000 infections per
year. Since the advent of hepatitis A vaccines, infection rates have declined sharply to an
estimated 3500 cases in 2006.
9. Groups that are at increased risk of acquiring hepatitis A :
- Travelers to developing countries from developed countries
- Men who have sex with men
- Users of injection and non-injection drugs
- Persons with clotting factor disorders
- Persons working with non-human primates.
10. Individuals with chronic liver disease are at increased risk for fulminant hepatitis if a
hepatitis A infection occurs. These groups should be vaccinated.
Hepatitis B
1. HBV is worldwide in distribution.
2. There are more than 250 million carriers, of whom about 1 million live in the United States;
25% of carriers develop chronic active hepatitis.
3. Worldwide, 1 million deaths a year are attributed to HBV-related liver disease and
hepatocellular carcinoma. There is a high burden of HBV infections among HIV infected persons,
with a 36% prevalence in 2008 in the United States.
4. The major modes of HBV transmission during infancy are from an infected mother to her
newborn during delivery and from an infected household contact to an infant.
5. There is no seasonal trend for HBV infection and no high predilection for any age group,
although there are definite high-risk groups :
- Parenteral drug abuser
- Institutionalized persons
- Health care personnel/Multiply transfused patients
- Organ transplant patients/Hemodialysis patients & staff
- Newborn infants born to mothers with hepatitis B
6. Since mandatory screening of blood donors for HBsAg was instituted, the number of cases of
transfusion-associated hepatitis has been dramatically reduced. People have been infected by
improperly sterilized syringes, needles, or scalpels and even by tattooing or ear piercing. The
estimated ratio of anicteric to icteric infections is reported to be as high as four to one.
7. HBsAg can be detected in saliva, nasopharyngeal washings, semen, menstrual fluid, and
vaginal secretions as well as in blood.
8. Transmission from carriers to close contacts by the oral route or by sexual or other intimate
exposure occurs.
9. There is strong evidence of transmission from persons with subclinical cases and carriers of
HBsAg to homosexual and heterosexual long-term partners.
10. Hepatitis B infections are common among patients and staff of hemodialysis units. As many
as 50% of the renal dialysis patients who contract hepatitis B may become chronic carriers of
HBsAg compared with 2% of the staff group, emphasizing differences in the host immune
response.
11. Family contacts are also at increased risk.

12. The incubation period of hepatitis B is 50–180 days, with a mean between 60 and 90 days.
It appears to vary with the dose of HBV administered and the route of administration, being
prolonged in patients who receive a low dose of virus or who are infected by a
non-percutaneous route.
Hepatitis C
1. Infections by HCV are extensive throughout the world.
2. The World Health Organization estimated in 1997 that about 3% of the world population has
been infected, with population subgroups in Africa having prevalence rates as high as 10%.
3. Other high-prevalence areas are found in South America and Asia.
4. It is estimated that there are more than 170 million chronic carriers worldwide who are at
risk of developing liver cirrhosis, liver cancer, or both and that more than 3 million of them are
in the United States.
5. HCV is transmitted primarily through direct percutaneous exposures to blood, although in
10-50% of cases, the source of HCV cannot be identified.
6. Prevalence of infection are :
- Injecting drug users (~80%)
- Individuals with hemophilia treated with clotting factor products before 1987, recipients of
transfusions from HCV-positive donors, chronic hemodialysis patients (10%)
- Persons who engage in high-risk sexual practices and health care workers (1%).
7. The virus can be transmitted from mother to infant, although not as frequently as for HBV.
Estimates of mother-to-child vertical transmission vary from 3% to 10%. Mothers with higher
HCV viral loads or co-infection with HIV more frequently transmit HCV.
8. No risk of transmission has been associated with breastfeeding.
9. HCV was found in saliva from more than one-third of patients with HCV and HIV co-infections.
10. HCV has been transmitted by commercial intravenous immune globulin (IG) preparations,
including an outbreak in the United States in 1994.
11. The population of Egypt has a high prevalence of HCV (~20%).
12. Transmission of HCV has been linked to an attempt (from the 1950s to 1980s) to treat the
parasitic disease schistosomiasis by therapy that involved multiple injections, often with
improperly sterilized or reused needles.
13. HCV infection has been associated with tattooing and, in some countries, with folk medicine
practices.
14. There was a case in 2009 in which HCV was transmitted to an organ transplant recipient by
the use of a blood vessel conduit from an HCV positive donor.
15. The average incubation period for HCV is 6-7 weeks. The average time from exposure to
seroconversion is 8-9 weeks, and about 90% of patients are anti-HCV positive within 5 months.
Hepatitis D (Delta Agent
1. HDV is found throughout the world but with a non-uniform distribution.
2. Its highest prevalence has been reported in Italy, the Middle East, central Asia, West Africa,
and South America. HDV infects all age groups.
3. Persons who have received multiple transfusions, intravenous drug abusers, and their close
contacts are at high risk.
4. The primary routes of transmission are believed to be similar to those of HBV, although HDV
does not appear to be a sexually transmitted disease. Infection depends on HBV replication
because HBV provides an HBsAg envelope for HDV.
5. The incubation period varies from 2 to 12 weeks, being shorter in HBV carriers who are
superinfected with the agent than in susceptible persons who are simultaneously infected with
both HBV and HDV. HDV has been transmitted perinatally, but fortunately, it is not prevalent in
regions of the world (e.g: Asia) where perinatal transmission of HBV occurs frequently.
6. Two epidemiologic patterns of delta infection have been identified. In Mediterranean
countries, delta infection is endemic among persons with hepatitis B, and most infections are
thought to be transmitted by intimate contact.
7. In non-endemic areas, such as the United States and northern Europe, delta infection is
confined to persons exposed frequently to blood and blood products, primarily drug addicts and
individuals with hemophilia.
8. Delta hepatitis may occur in explosive outbreaks and affect entire localized pockets of
hepatitis B carriers. Outbreaks of severe, often fulminant and chronic delta hepatitis have
occurred for decades in isolated populations in the Orinoco and Amazon basins of South
America.
9. In the United States, HDV has been found to participate in 20-30% of cases of chronic
hepatitis B, acute exacerbations of chronic hepatitis B, and fulminant hepatitis B, and 3-12% of
blood donors with serum HBsAg have antibodies to HDV.
10. Delta hepatitis is not a new disease because globulin lots prepared from plasma collected in
the United States more than 40 years ago contain antibodies to HDV.
Malaysia
Malaysia is a country where an estimated 1 million people are chronically infected with
hepatitis B virus (HBV) and an estimated 2.5% of the adult population are positive for antibody
to hepatitis C virus (HCV). Effective nationwide vaccine coverage seems to be a highly effective
measure to prevent new HBV infection. Treatment of HCV infection is also a regular practice in
Malaysia. These measures highlight the possibility to reach the World Health Organization
elimination target by 2030. To achieve this target, the Health Ministry and other
nongovernmental organizations, such as My Commitment to Cure (MyC2C) are working
together to develop a strategic road map to reach the global elimination target in Malaysia by
2030.